2014-05-13T07:26:08-05:00 2013-06-30 010494526 BAKER NEWMAN & NOYES PO BOX 507 PORTLAND ME 04112 990 2012-07-01 020519436 Alliance Ambulatory Services ALLI 6036683545 100 McGregor Street Manchester NH 03102 Edward L Dudley III 6036683545 2014-05-09 Nicholas E Porto P01310283 2078792100 2012 2015-11-30 17:44:51Z Joseph Pepe MD 100 McGregor Street Manchester NH 03102 2266656 0 0928 X www.catholicmedicalcenter.org X 2000 NH To promote and generate healthcare programs for a broad cross-section of the greater Manchester, New Hampshire community 19 14 0 14 0 0 0 0 2878179 2266573 224 83 0 0 2878403 2266656 0 0 0 0 0 0 0 0 0 64 0 64 0 2878339 2266656 6484141 6176712 0 915 6484141 6175797 To create and promote healthcare programs in the Manchester New Hampshire, community. 0 0 0 2266573 Revenue from partnership interest in Bedford Ambulatory Surgical Center, LLC 1 0 0 0 0 0 0 0 0 0 0 1 1 1 0 1 0 1 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 1 1 0 0 1 0 0 0 0 0 0 0 0 0 0 0 X 19 14 0 0 0 0 1 1 1 1 1 0 1 1 1 1 1 1 1 1 1 1 0 NH X Edward L Dudley III 6036683545 100 McGregor Street Manchester NH 03102 Adele Boufford Baker 1.00 4.00 X 0 0 0 Gary Bouchard PhD 1.00 3.00 X 0 0 0 William Clutterbuck MD 1.00 43.00 X 0 336211 33424 John G Cronin Esq 1.00 3.00 X 0 0 0 Eleanor Wm Dahar Esq 1.00 3.00 X 0 0 0 Raef Fahmy DPM 1.00 43.00 X 0 147346 4431 Connor J Haugh MD FACC 1.00 43.00 X 0 631859 40161 Powen Hsu MD 1.00 3.00 X 0 0 0 Susan Huard PhD 1.00 3.00 X 0 0 0 Maria C Mongan 1.00 4.00 X 0 0 0 Diane Murphy Quinlan Esq 1.00 3.00 X 0 0 0 Msgr John P Quinn 1.00 4.00 X 0 0 0 Keith A Stahl MD 1.00 43.00 X 0 261526 37300 Fr Patrick Sullivan OSB RN 1.00 4.00 X 0 0 0 Guy D Chapdelaine 1.00 3.00 X 0 0 0 Joseph Graham 1.00 5.00 X X 0 0 0 Rick Botnick 1.00 3.00 X X 0 0 0 Suzanne K Mellon PhD RN 1.00 3.00 X X 0 0 0 Margaret-Ann Moran Esq 1.00 5.00 X X 0 0 0 Daryl J Cady CPA 1.00 4.00 X X 0 0 0 Joseph Pepe MD 1.00 45.00 X X 0 495191 92176 Edward Dudley III 1.00 43.00 X 0 423816 103350 Allen Ericson 1.00 43.00 X 0 325490 64430 Alyson Pitman Giles 0.00 X 0 2917789 23652 Raymond Bonito 0.00 X 0 131906 1822 0 5671134 400746 0 1 1 0 0 Interest in Ambulatory 621990 2266573 2266573 2266573 83 83 2266656 2266573 0 83 0 0 0 0 161225 282222 6322916 5894490 6484141 6176712 0 915 0 915 X 6484141 6175797 6484141 6175797 6484141 6176712 X 2266656 -2575000 X X 0 1 X 1 0 X X X 0 0 0 CMC 020315693 3 1 1 2575000 1 2575000 0 Investment in Bedford Ambulatory Surgical Care 5894490 F 5894490 X 2266656 0 2266656 0 2266656 0 0 0 0 0 Description of Uncertain Tax Positions Under FIN 48: Part X, Line 2: The Medical Center, PPA, Resources, AAS, Hillcrest, AHS, DMA and St. Peter's Home, Inc. are not-for-profit corporations as described in Section 501(c)(3) of the Internal Revenue Code (the "Code") and are exempt from federal income taxes on related income pursuant to Section 501(a) of the Code. 1 1 0 0 0 0 0 0 0 William Clutterbuck MD 0 336211 0 0 0 0 0 15000 0 18424 0 369635 0 0 Raef Fahmy DPM 0 147346 0 0 0 0 0 4420 0 11 0 151777 0 0 Connor J Haugh MD FACC 0 507021 0 124838 0 0 0 20000 0 20161 0 672020 0 0 Keith A Stahl MD 0 205126 0 56400 0 0 0 16959 0 20341 0 298826 0 0 Joseph Pepe MD 0 427363 0 67828 0 0 0 63982 0 28194 0 587367 0 0 Edward Dudley III 0 341812 0 82004 0 0 0 58650 0 44700 0 527166 0 0 Allen Ericson 0 266779 0 58711 0 0 0 43846 0 20584 0 389920 0 0 Alyson Pitman Giles 0 802717 0 82095 0 2032977 0 17500 0 6152 0 2941441 0 1339641 Raymond Bonito 0 103906 0 28000 0 0 0 1822 0 0 0 133728 0 0 Part I, Line 3 The Organization's President and CEO's compensation was established by a related organization, Catholic Medical Center. That organization used a compensation committee, independent compensation consultant, the Form 990 of other organizations, a compensation study/survey, and approval by their board of directors/compensation committee to determine the President and CEO's compensation and benefits. Part I, Lines 4a-b Part I, Lines 4a-b: 4A: The following individual received base compensation under a severance agreement from a related organization (Catholic Medical Center). Alyson Pitman Giles: $279,802 4B: The following individuals take part in a section 457(f) forfeitable nonqualified deferred compensation plan through Catholic Medical Center (a related organization). The following represents contributions for many years of service. Alyson Pitman Giles: $270,207 Joseph Pepe: $43,982 Edward Dudley, III: $43,650 Allen Ericson: $27,269 Supplemental Information Part III Schedule J, Part II, Column F: Box 5 of Alyson Pitman Giles's W-2 reflects payouts of deferred compensation that was accrued in prior years dating back to 2001. The amount in Column F may not be reflective of all compensation that was reported on previous 990s due to changes in reporting requirements with the redesigned form. Form 990, Part VI, Section A, line 6 The sole member of Alliance Ambulatory services is CMC Healthcare System. Form 990, Part VI, Section A, line 7a The directors of Alliance Ambulatory Services are appointed by the sole member. Form 990, Part VI, Section A, line 7b The sole member has reserved powers over Alliance Ambulatory Services but does not approve each separate action taken by the Alliance Ambulatory Services board. Form 990, Part VI, Section B, line 11 Form 990 is prepared by the Organization, and is sent to an independent tax accounting firm (Baker, Newman, Noyes) for a thorough and exhaustive review. Upon completion of independent firm review, Form 990 is sent back to the Organization, where the CFO, Controller, and Director of Accounting perform a final in-house review prior to submission to the Board of Directors for final approval. Upon approval from Board, Form 990 is filed with the Internal Revenue Service. Form 990, Part VI, Section B, line 12c Officers are required to complete a conflict of interest policy annually. Form 990, Part VI, Section B, line 15 A related organization, Catholic Medical Center utilizes a compensation committee of the board of directors to set compensation levels and determine bonus potential for its senior leadership team. The committee is assisted by an independent consultant who surveys like-sized and performing institutions to benchmark relevant salary scales for each position. The consultant's findings are presented to the compensation committee who considers that external data with actual performance against a list of pre-established goals per senior leaders to set prospective compensation levels and bonus values. Bonus amounts are determined by how well an executive achieves a pre-defined set of goals. These goals, in general, are tied to the achievement of a specific task or project. Some goals are attached to achieve overall financial performance and mission performance, not solely revenue generation. Form 990, Part VI, Section C, line 19 The Organization makes its governing documents, conflict of interest policy, and financial statements available to the public upon request. Changes in Net Assets or Fund Balances: Form 990, Part XI, line 9: Net Transfer to Affiliates -2,575,000. Form 990, Part XII, Line 2c: The audit process has not changed from the prior year. Alliance Health Services 100 McGregor Street Manchester NH 03102 611508839 Practices NH 501(c)(3) Line 11b, II CMC Healthcare System 0 Catholic Medical Center 100 McGregor Street Manchester NH 03102 020315693 Hospital NH 501(c)(3) Line 3 CMC Healthcare System 0 CMC Healthcare System 100 McGregor Street Manchester NH 03102 010568516 Parent NH 501(c)(3) Line 11b, II N/A 0 CMC Associates 100 McGregor Street Manchester NH 03102 020344786 Gift Shop NH 501(c)(3) Line 11b, II CMC 0 CMC Physician Practice Associates 100 McGregor Street Manchester NH 03102 020460245 Practices NH 501(c)(3) Line 11b, II CMC Healthcare System 0 St Peters Home 100 McGregor Street Manchester NH 03102 020222228 Home NH 501(c)(3) Line 9 CMC Healthcare System 0 Alliance Resources 100 McGregor Street Manchester NH 03102 020398138 Real Estate NH 501(c)(3) Line 11b, II CMC Healthcare System 0 McGregor Steet MOB LLC 100 McGregor Street Manchester NH 03102 134347316 Medical Office Building NH CMC Healthcare System Related 0 0 Doctors' Medical Association 100 McGregor Street Manchester NH 03102 020340690 Medical Office Building NH CMC Healthcare System C 0 Alliance Enterprises 100 McGregor Street Manchester NH 03102 020386795 Real Estate NH CMC Healthcare System C 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 Bedford Ambulatory Surgical Center LLC 11 Washington Place Bedford NH 03110 020519727 Outpatient surgery NH Related 0 2311463 3342764 0 1 0.50000